Download patient controlled analgesia (pca)

Patient Controlled Analgesia (PCA) Policy
For Adult and Paediatric Patients
Ratifying Committee: Clinical Standards Committee
Ratified Date: September 2009
PATIENT CONTROLLED ANALGESIA (PCA) POLICY
FOR ADULT AND PAEDIATRIC PATIENTS
ID number
Author’s name
Author’s job title
Division
Department
Version number
Ratifying Committee
Ratified date
Review date
Name of manager responsible for review
Job title of manager responsible for review
Email address for this manager
Source of evidence (if applicable)
Level of evidence indicated
Referenced (Yes/No)
Key words (to aid searching)
User Group
2009-47
Linda Loader
Clinical Nurse Specialist Lead for
Acute Pain Management.
Anaesthetics/ surgery
Anaesthetics and Pharmacy
Version 1
Integrated Standards Executive
September 2009
September 2011
Clinical Nurse Specialist Lead for
Acute Pain Management / Consultant
Anaesthetists
As references in document
Data not synthesised
Yes
Policy, guideline, PCA; Morphine;
Pethidine; Fentanyl; Analgesia; Pain;
injections; Paediatric.
All Staff who are involved in the care
of patients with analgesia
The Trust is committed to promoting an environment that values diversity. All staff are
responsible for ensuring that all patients and their carers are treated equally and fairly and
not discriminated against on the grounds of race, sex, disability, religion, age, sexual
orientation or any other unjustifiable reason in the application of this policy, and
recognising the need to work in partnership with and seek guidance from other agencies
and services to ensure that special needs are met.
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Contents
ADULTS PART 1
CHILDREN PART 2
Page
1.
2.
3.
4.
4.1
4.2
4.3
4.4
5.
6.
7.
8.
9.
10.
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
11.
12.
13.
14.
Adults Part 1
Acute Pain Service Contact Details……………………………………...
Introduction ………………………………………………………………...
Aims………………………………………………………………………...
Education and Training……………………………………………………..
Patients Selection…………………………………………………………...
Contra-indications for PCA………………………………………………...
Extra care should be exercised in the selection of patients if they
have:…
Age Related Considerations……………………………………………...
Personality Traits………………………………………..………………...
Patient Information…………………………………………………………
PCA Prescription……………………………………………………………
Multi-Modal Analgesia……………………………………………………..
Equipment…………………………………………………………………..
Monitoring and Documentation…………………………………………….
Side Effects and Problems……………………………………………….
Nausea and Vomiting………………………………………………………
Respiratory Depression and Over Sedation………………………………
Inadequate Analgesia………………………………………………………
Urinary Retention…………………………………………………………...
Mobility………………………………………………………………………..
Pruritis………………………………………………………………………
Constipation………………………………………………………………...
Pump Problems……………………………………………………………..
Discontinuation …………………………………………………………….
Decontamination of PCA machine……………………………………….
Successful outcome criteria……………………………………………….
Monitoring compliance and effectiveness………………………………...
References…………………………………………………………………
Appendix 1. Guidelines for preparing Fentanyl PCA……………………
Appendix 2. Guidelines for preparing Pethidine PCA……………………
Appendix 3. PONV guideline………………………………………………
2
3
3
3
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3
4
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6
7
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14-15
16
Children Part 2
Page 1 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Acute Pain Service West Herts NHS Trust
Contact Details
Lead Consultant: - Dr. David Redman via anaesthetic office at WGH ext. 7604
Watford General Hospital (WGH):Clinical Nurse Specialists (CNS):Linda Loader, Lead CNS for Acute Pain. Pager 07659 106855
Michelle Ashwell, CNS for Acute Pain,
Judith Nayler, CNS for Acute Pain, Pager 07659 130558
Tracey Robertson, CNS for Acute Pain,
WGH ext. 3120; bleep 1120
SACH ext. 4660; bleep 2976
---------------------------------------------------------------------------
For Out of Hours Service and Covering Annual Leave
The Clinical Nurse Specialist will hold the Acute Pain bleep during working hour’s site specific.
st
The 1 on call anaesthetist will cover out of hours and Bank Holidays, please be aware that you may
not receive immediate response as they may be otherwise engaged. If there is no response, try the
on call anaesthetic registrar for ICU.
-------------------------------------------------
Page 2 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
1. Introduction
This policy covers the care and maintenance of Patient Controlled Analgesia systems (PCAs) within
West Hertfordshire Hospitals NHS Trust (WHHT). Part one of this policy is applicable to adult
patients, part two to paediatric patients.
Wards and departments must be deemed competent in caring for patients receiving PCA by the ward
/ department manger. The manager holds responsibility for arranging training for their staff in the use
of PCAs.
2. Aims
The aims of this policy are:• To provide education and the rationale behind the uses of the PCA pump
• To provide consistent and effective pain relief through education
• To maintain patient safety and comfort by reducing and preventing side effects and problems
in the first instance and managing them effectively if they do occur.
3. Education and Training
3.1 Training and education is available via the ‘WHHT Learning Package for Nurses caring for Adult
Patients using Patient Controlled Analgesia Systems’ provided by the Acute Pain Service (APS). The
ward manager will identify any candidates needing training. Training should be booked through the
training department. Updates for training will be required every two years when new competency
sheets will be issued. It is the responsibility of the individual nurse and ward managers to access staff
training needs.
3.2 Patients receiving a PCA can only be cared for in an area where there are registered nurses who
have been deemed competent in caring for patients receiving PCA.
3.3 The Acute Pain Team (APT) advise that all wards that accept patients with PCA should have an
Acute Pain Link Nurse who has been deemed competent in caring for patients receiving PCA. It is
the ward manager’s responsibility to identify their ward Link Nurse.
4. Patient Selection
PCA can be used for any patient with acute pain, where repeated doses of intramuscular or
intravenous opioids would otherwise be anticipated. This will include post-operative patients and
patients with acute painful conditions such as pancreatitis and sickle cell disease etc.
4.1 Contra-indications for PCA:
• Patient refusal
• Physical inability to operate the PCA demand button
• Impaired mental status
• Head injury
• Insufficient numbers of trained staff to ensure patient safety
4.2 Extra care should be exercised in the selection of patients if they have:
•
A history of obstructive airway disease
•
Marked electrolyte imbalance
•
Opioid dependence
•
Previous history of opioid related side effects
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
4.3 Age Related Considerations
Old age should never be considered a barrier for PCA use. However, the physical ability, attitudes
and characteristics of the elderly population should be taken into consideration when deciding if a
PCA is appropriate.
A characteristic of some elderly people may be that they expect to experience pain following
surgery1. Explaining the negative effects of pain does not always encourage them to use more
analgesia and they may experience better pain relief if the Health Care Professional administers their
pain relief via an alternative method, rather than a PCA machine.
4.4 Personality Traits
Not everyone benefits from PCA. It is beneficial for patients who like to maintain control of their
environment, but some patients do not want to accept this responsibility. Some people like to block
2
out potentially unpleasant experiences and are more likely to expect the Health Care Professional to
take responsibility for their pain relief. These people are unlikely to use the PCA to its full potential.
If PCA is not being used effectively, it can be equivalent to no pain relief at all; therefore the method
of pain relief should be reviewed. Contact the APT Monday – Friday 9.00 – 17.00, outside these
hours contact the first on call anaesthetist, an alternative mode of analgesia may be decided upon.
Many people fear addiction to analgesia and may have been exposed to negative reports of opioids
from the media. This fear may have taken years to develop and rarely subsides with a brief
discussion about the use of opioids for pain relief3,4. This may affect their willingness to utilise the
PCA to its full potential.
Patients’ appropriateness for PCA will be decided by the anaesthetist or Acute Pain Clinical
Nurse Specialist after discussion with the patient and ward nurse.
5. Patient Information
Patients in whom PCA is planned should receive an explanation of the technique by the Anaesthetist
/ Nursing staff. This should then be reinforced when appropriate in the recovery unit. Ward staff
should also provide the patient with verbal information about the PCA. The written information ‘Pain
after Surgery’ can be obtained from the ward and / or pre assessment clinic.
It is sometimes possible to highlight and address any concerns the patient may have when
counselling them for PCA use5.
6. PCA Prescription
6.1 The PCA must be prescribed on the PRN side of the prescription chart, including the route, drug
concentration, bolus size and lockout period; this should be signed and dated by the prescriber e.g:Drug: Morphine sulphate via PCA
Additional Instructions
50mg morphine in 0.9% Sodium Chloride
Total 50ml pre filled syringe
Signature:
Jo Brown
Dose:
1mg bolus
Route
Date:
IV
25/12/2010
Max. Frequency
5min. lock out
Any loading doses should be prescribed as ‘stat doses’ on the front of the drug chart, in the once only
section.
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
6.2 For adults a standard pre-filled syringe of morphine sulphate solution should be used:- morphine
sulphate 50mg in a total of 50ml of 0.9% sodium chloride. Using pre filled syringes that the Trust
purchases, is aimed at reducing the risk of needle stick injury and error of incorrect dilution. If these
are not available, Pharmacy should be contacted for further guidance.
6.3 Other opioids may be used as an alternative if morphine is not appropriate for the patient, but
must be discussed with an Anaesthetist or the Acute Pain CNS first. See Appendix 1 and 2.
6.4 The pumps should only be programmed by an Anaesthetist, Acute Pain CNS, trained recovery
staff or a member of staff who has been specifically trained by the Acute Pain CNS and deemed
competent to do so.
6.5 PCA syringes can be changed by any qualified nurse who has been assessed as
competent in administering intravenous medication and successfully completed the ‘WHHT
Learning Package for Nurses caring for Adult Patients using Patient Controlled Analgesia
Systems’.
6.6 Additional doses of opioids (loading doses) should only be administered by the Anaesthetist or
Acute Pain CNS. Qualified nursing staff in recovery who have been deemed competent by the
Recovery Unit Sisters, may administer loading doses as prescribed for patients in recovery.
6.7 Naloxone should always be prescribed on the PRN side of the drug chart when a PCA is in use. It
should be administered to keep the patients respiratory rate greater than 8 breaths per minute.
Naloxone 400 micrograms made up to a total of 8mls with 0.9% sodium chloride.
Give 2mls (100 micrograms) observe effect; repeat every 2 minutes if required, Naloxone has a short
duration of action, maximum dose of 10 mg. A continuous intravenous infusion may be required8.9.
7. Multi-modal Analgesia
Using only one approach to managing pain can be ineffective for many patients; several different
pains may contribute to their overall symptoms7. A balanced approach, using several analgesics with
differing mechanisms of action, has been shown to be more effective and to reduce the risk of side
effects of opioids. A combination of different drugs that act at different stages of the pain pathway
maximise the amount of pain relief. All drugs should be correctly prescribed on the patients drug
chart before administration.
Where possible PCA should be given concurrently with paracetamol pr/iv/po and/or a Non Steroidal
Anti Inflammatory Drug, (NSAID) via an appropriate route, ensure NSAID’s are not contraindicated,
(see BNF for contraindications8). It is not advisable to give diclofenac (Voltarol) intramuscularly as it
is very painful and can cause abscesses and local necrosis at the intramuscular injection site6.
Paracetamol and/or a NSAID should be given on a regular basis in conjunction with the PCA if
prescribed.
No other opioids including codeine, dihydrocodeine, tramadol or compound analgesics i.e. codydramol should be administered whilst the patient is receiving PCA, (this will minimise the risk of
respiratory depression) unless advised by Anaesthetist or Acute Pain CNS and concurrent
administration must be stated on the drug chart.
8. Equipment
8.1 PCA delivery is via the Graseby 3300 machine that requires a 50 ml syringe clearly identified with
the drug and concentration, patients’ details, date and time infusion commenced. An appropriate
giving set with anti-syphon and anti-reflux properties must be used and a labelled PCA line, these
can be obtained from the recovery unit if required.
8.2 The opioid of choice and purchased as pre filled syringes for PCA use is Morphine Sulphate
1mg/1ml in a 50 ml syringe these are available to order from Pharmacy. These pre filled syringes can
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
be used for patients over 50 kg, for patients under 50 kg the correct morphine concentration will have
to be prepared by the nursing or medical staff.
8.3 The PCA must have a dedicated Vygon PCA administration line which has an anti syphon value
at the distal end that attaches to the syringe. Its other property is, at the proximal end (patient end)
there is a side port with anti reflux value where maintenance fluids or other infusions that are
compatible with the morphine, may be attached. The use of the side port helps prevent premature
blockage of the cannula and reduces the need for separate flushing of the cannula or the need for a
second cannula.
8.4 All IV cannulas and lines must be changed according to hospital policy, 48 hours for solution
sets10. The giving sets for PCAs are kept in recovery. The Graseby 3300 pump can be obtained from
the Medical Electronics Library 09.00 – 17.00 Monday to Friday and from recovery out of hours. The
morphine sulphate syringe should be obtained form the ward / department controlled drug cupboard
the patient is in at the time.
8.5 The patients’ cannula should be secured with a transparent dressing. The administration line
tubing can then be secured to the patient if required. The cannula should be easily visible and
accessible (see 9.4 below).
9. Monitoring and Documentation
9.1 All patient vital signs /clinical observations for the duration of the PCA should be recorded on the
front of the patients observation chart.
9.2 Frequency for monitoring vital signs
Monitor
First
hour
¼ hrly
Next
2
hours
½ hrly
Next
4
hours
1hrly
Respiratory
rate
Remainder of time while on
PCA
1-2hrly
Sedation score
¼ hrly
½ hrly
1hrly
1-2hrly
Blood Pressure
¼ hrly
½ hrly
1hrly
According to clinical need
Heart Rate
¼ hrly
½ hrly
1hrly
According to clinical need
Pain Score
¼ hrly
½ hrly
1hrly
According to clinical need
The patients’ respiratory rate and sedation score should be monitored 1-2 hourly for the duration of
the PCA according to clinical need; this is necessary due to the side effect profile of opioids.
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
9.3 The following observations are also mandatory when a patient is receiving opioids via a PCA and
should be documented 2-4hrly in the appropriate place on the PCA observation chart or more
frequently if clinically indicated.
Pain score∗
Nausea and vomiting score
Cumulative dose of morphine
Number of demands on the PCA machine
* Pain score should always be assessed on movement e.g. coughing, deep breathing. If the pain
score is greater than 1 (0 = none 3 = severe) at any time this must be addressed and reassessed in
½ hour and then recorded hourly until a score of 1 or below has been established.
Pain cannot be treated adequately if it is not assessed regularly
9.4 IV cannula site to be checked 4 hourly for inflammation, redness etc. If indicated the cannula
should be re-sited.
9.5 The Acute Pain Team aim to visit the patients daily if possible Monday to Friday.
In the absence of the Acute Pain Nurse the 1st on call anaesthetist should be contacted to deal with
any pain management problems that the patients’ clinical teams cannot manage.
9.6 All patients receiving PCA should have a Pain Service Audit Sheet stared in recovery. The
Recovery staff should fill this in if the patient has been nursed in Recovery. The audit form ensures
that the patient will receive appropriate follow-up care by the Acute Pain Team.
9.7 If patients with PCA are returning to the wards from the Intensive Care Unit (ICU), ICU staff
should inform the Acute Pain Nurse regarding the patients transfer.
10. Side Effects and Problems
10.1 Nausea and vomiting
The incidence of postoperative nausea and vomiting depends on many factors including the
anaesthetic used, the type and duration of surgery and the patient’s sex. The aim is to prevent
postoperative nausea and vomiting from occurring. The nurse or doctor should evaluate the response
to any anti-emetic after administration and if the patient is still nauseated after 30 minutes a different
type of anti-emetic should be prescribed and administered. A combination of two antiemetic drugs
acting at different sites may be needed in resistant postoperative nausea and vomiting.
The following are recommended by the APS:
1st drug of choice – CYCLIZINE 50mg IV/IM/PO 8 hourly (maximum 150 mg in 24 hours)
2nd drug of choice – ONDANSETRON 4mg IV/IM/PO 8 hourly or 8mg 12 hourly (maximum 16 mg in
24 hours)
If postoperative nausea and vomiting (PONV) persists when the above are given regularly then
contact the APS or anaesthetist.
PCA should not be stopped because of nausea and vomiting unless prior discussion with the APS
has taken place.
Patients with a high risk of PONV can be prescribed one anti-emetic on a regular basis and one on
an as required basis. (Refer to PONV algorithm, appendix 3)
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
10.2 Respiratory Depression and Over Sedation
10.2.1 If the respiratory rate is 8 or below and sedation score1 or 2;
•
•
•
•
•
Remove the hand set from the patient
Commence ¼ hourly respiratory rate and sedation scoring
Commence and maintain continuous pulse oximetry
Give oxygen as necessary according to prescription, keeping saturations above 90%
Inform Acute Pain Team and/or 1st on-call anaesthetist
10.2.2 If the sedation score is 3 irrespective of respiratory rate or respiratory rate 6 or below:
•
•
•
•
•
•
•
•
•
Stop PCA
Administer high flow oxygen at 10-15 litres via a non-rebreathe bag and mask. This may
be administered without prescription in accordance with Trust oxygen policy.11
Fast bleep the 1st on-call anaesthetist or anaesthetic registrar. Also clinical team
managing patient.
Commence pulse oximetry
Commence ¼ hourly observations of respiratory rate and sedation score.
Ensure a qualified nurse remains with the patient.
Prepare naloxone injection (400mcg diluted with 0.9% sodium chloride for injection to
8ml)
Give 100mcg/2ml every 2 minutes and observe effect. Repeat assessment of sedation
score and respiratory rate.
If sedation score remains 3 or respiratory rate of 6 or below, repeat administration of
naloxone every 2 mins to keep respiratory rate above 8.
WHHT Guidelines for Administration of Naloxone for Adult Patients Receiving Patient
12
Controlled Analgesia and Opioid Epidural Analgesia .
For APNOEA give prescribed Naloxone and initiate Basic Life Support Guidelines.
10.3 Inadequate Analgesia
If a patient has a pain score of greater than 1 (0=none 3=severe) on movement, action needs to be
taken.
There are several interventions that can be used and the choice will depend on the assessment of
the patient. This should, where possible, be negotiated with the patient. These are:
•
•
•
•
•
•
Re-educate patient in using PCA
Give prescribed multimodal analgesia
Has the handset become disconnected from back of PCA pump?
Arrange for morphine bolus via PCA to be given (only given by anaesthetist or Acute
Pain Team. Recovery Nurse, once prescribed, in recovery only)
Reassure / Re-position patient.
Always check the IV site for patency and IV line that all clamps are open. That there is
no extravasations or signs of infection
PCA should not be stopped because of inadequate analgesia without prior discussion with
the APS.
The bolus dose may need to be increased, discuss with Acute Pain Team or
Anaesthetist on-call.
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
10.4 Urinary Retention
Contact the F1 team doctor for advice; the patient will need an assessment and may require a urinary
catheter.
10.5 Mobility
Using a PCA does not prevent patients from mobilising. It is when the patient first starts to mobilise
that they may need to use the PCA more. The Graseby 3300 PCA pumps may be disconnected from
the electrical mains supply and can run on battery power for a short period of time (up to 7 hours
depending on battery charge). However to recharge the battery the pumps should always be plugged
in when possible.
PCA should not be stopped because the patient needs to mobilise.
10.6 Pruritis
If problematic for the patient, contact the doctor, APT to assess the patient. Chlorphenamine may be
prescribed, as required, 10mg im/iv given over 1 minute, 4 times in 24 hours, or
15
0.2micgrograms/kg/hr dose of naloxone may be required . If a higher dose of naloxone is given this
will reverse the analgesic effect of the opioid.
10.7 Constipation
Patients receiving opioid analgesia may require a laxative prescribed regularly or the appropriate
health education to help manage any constipation.
10.8 Pump Problems
If the pump alarms, the cause for the alarm will appear on the pump screen. Check the cause by
reading the screen then silence the alarm. Refer to Manufacturers Guidelines (found in The Acute
Pain Resource Folder) to resolve these problems. Ensure PCA line is not clamed in PCA lid and that
all line clamps are open.
If a fault code appears:•
•
•
•
Turn off the pump immediately and remove it from the patient
Call the APT / Anaesthetist to initiate another PCA pump if the ward staff are not trained to do
so.
Medical Electronics Library should be informed of the type of fault as soon as possible.
Document the pump number and fault code that appeared on the pump. Attach this
information to the pump to assist in the correct pump being serviced.
Consider if an Incident Form needs to be completed e.g. incorrect dose of morphine being
administered.
11. Discontinuation
If a patient is comfortable and pain free, it is likely that the patient’s analgesia is at a correct level. It
is not necessarily an indication for stopping the PCA. However, once a patient is able to eat and drink
and their PCA opioid usage is minimal this may be an appropriate time to consider changing the
analgesia to oral medications.
The PCA opioid should be discontinued after discussion and agreement with the patient. The patient
should be able to transfer onto oral medication. It is not advisable to stop PCA analgesia in favour of
intramuscular analgesia.
Initially after stopping the PCA analgesia oral analgesia should be given regularly. The multimodal
rules (see section 7 above) also apply to oral analgesia. If the patient has not been taking
supplementary analgesia such as paracetamol and / or NSAIDs (if no contraindications), commence
this prior to stopping the PCA. This will reduce the level of mild or strong opioid analgesia the patient
will require.
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
After discontinuation of the PCA, the pain score should continue to be documented on the front of the
Patient Observation chart with every set of observations, remembering that pain is the 5th vital sign.
This is vital in order to assess that the alternative oral analgesia continues to control the patient’s
pain adequately.
Any remaining opioid in the PCA syringe when discontinued must be destroyed, put into gauze/paper
towel and put into the clinical waste bin/sharps bin, as per ‘WHHT, Medicines Management Policy,
incorporating, The Policy for Prescribing, Administration and Supply of Drugs’13.
When the PCA has been discontinued the PCA pump should be decontaminated and returned to the
Medical Equipment Library at WGH and Recovery Unit at SACH.
PCA should not be discontinued within 24 hours of surgery without prior discussion with the
APS, unless the patient is being discharged home.
12. Decontamination of PCA machine
The pump may be cleaned in lines with ‘WHHT Decontamination Policy including Management of
Blood and other Body Fluid spillage.14
13. Successful outcome criteria
• Patient indicates that their pain level is at a level acceptable to them
• Patient indicates that they are satisfied with this method of analgesia
• Patient indicates that they have participated in their own pain management
• There is written evidence that the patient has a pain score of 0 or 1
14. Monitoring Compliance and Effectiveness
• Annual Audit
• Acute Pain Team will audit all patients with PCAs on a daily basis (other than weekends and bank
holidays when it is down to the on call anaesthetist) any deviations from the policy will be reported
and monitored through Clinical Governance Meetings.
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
References
1. Taylor N M, Hall G M and Salmon P. Patients’ experiences of patient controlled analgesia.
Anaesthesia 1996 51: 525 – 528
2. Miller S. Monitoring and Blunting; validation of a questionnaire to assess styles of information
seeking under threat. Journal of Personality and Social Psychology. 1987: 52 (2): 345 – 353
3. Obituaries, Harold Shipman. BMJ 2004.328
4. Dept of Health. Harold Shipman’s clinical practice 1974-1998: A clinical audit commissioned by
the Chief Medical Officer. 2001
5. Thomas V. Heath M, Rose D and Flovy P. Psychological characteristics and the effectiveness of
patient controlled analgesia. British Journal of Anaesthesia 1995. 74: 271 – 276
6. Mc Gee A.M. and Davison P. M. Skin necrosis following injection of non-steroidal anti-inflammatory
drug. British Journal of Anaesthesia 2002. 88 (1): 139-140
7. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. British
Journal of Anaesthesia 1997. 78. 606-617
8. BNF, British National Formulary (refer to latest edition)
9. WHHT. Guideline for Administration of Naloxone for Patients receiving PCA and Opioid Epidural
Analgesia
10. WHHT, Policy for Safe Practice of Intravenous Drug administration. 2005
11. WHHT, Policy for Safe Prescribing and Administration of Oxygen for Adults. (Under review)
12. WHHT - Guideline for Administration of Naloxone for Adult Patients receiving Patient Controlled
Analgesia and Opioid Epidural Analgesia. Acute Pain Team. (under review)
13. WHHT, Medicines Management Policy, incorporating, The Policy for Prescribing, Administration
and Supply of Drugs 2009.
14. WHHT, Decontamination Policy including Management of Blood and other Body fluid spillage.
2008
15 Kjellberg F. and Tramer M.R. Pharmacological control of opioid-induced pururitus: a quantitive
systematic review of randomized trials. European Journal of Anaesthesiology (2001)
Appendix 1
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Guideline on preparing Fentanyl PCA
Pump used
Concentration after dilution
Drug
Graseby 3300 PCA
Fentanyl IV 20 mcg per 1 ml
Fentanyl 1000 mcg
(Two 10ml 500 mcg amps. total 20ml)
Dilute with
30 mls Normal Saline 0.9% (to a total of
50ml )
Bolus dose
20 mcg /1 ml
5 minutes
Lockout time
Please note:
The anaesthetist / Acute Pain CNS are responsible for assessing and making the decision to use IV
Fentanyl via the PCA. A valid prescription needs to be written before administration.
The Trust does not purchase Fentanyl in pre-filled syringes. It will therefore have to be prepared in
the clinical area.
Most wards do not stock IV Fentanyl on a regular basis; therefore it needs to be ordered in the ward
controlled drug order book in the normal way for ordering controlled drugs. Ensure availability of
Fentanyl stock whilst PCA in use.
Nurses who have successfully completed the Trust IV training course may make up subsequent
syringes, if competent. If the nurse is not IV trained or not feeling competent to do so, the Acute Pain
CNS or out of hours the on call anaesthetist may be asked.
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Appendix 2
Guideline on preparing Pethidine PCA
Pump used
Concentration after dilution
Graseby 3300 PCA
Pethidine IV 10 mg per1 ml
Pethidine 500 mg
Drug
Dilute with
Normal Saline 0.9% made up to a total of
50 mls
Bolus dose
10 mg / 1 ml
5 minutes
Lockout time
Please note:
The anaesthetist / Acute Pain CNS are responsible for assessing and making the decision to use IV
Pethidine via the PCA. A valid prescription needs to be written before administration.
The Trust does not purchase pethidine in pre-filled syringes. It will therefore have to be made in the
clinical area.
The ward may not stock IV pethidine on a regular basis; therefore it needs to be ordered in the ward
controlled drug order book in the normal way for ordering controlled drugs. Ensure availability of
pethidine stock whilst PCA is in use
Nurses who have successfully completed the Trust IV training course may make up the subsequent
syringes if competent. If the nurse is not IV trained or not feeling competent to do so, the Acute Pain
CNS or out of hours the on call anaesthetist may be asked.
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Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Appendix 3
Guidelines for the management of postoperative nausea and vomiting (PONV) in adult patients
Risk Factors
Female Gender
History of PONV or motion sickness
Postoperative opioids
Non-smoker
Chance of PONV
0-1 Score – Low risk (10-20%)
Score 1 point for each factor
3-4 Score - High risk (60-80%)
2 Score – Moderate risk (40%)
present
Score predictability is no more than 70% accurate (Apfel et al 1999)
Prophylaxis intra-operative
Risk
Prophylaxis
Low
None
Moderate
Cyclizine 50mg IV 20 min. before end of surgery
High
Combination of Cyclizine 50mg IV and Ondansetron 4 mg IV
The above table is for guidance. Doctors may use their discretion to allow for individual patient characteristics
Prescription for postoperative period
Risk
Prescription
Low
Cyclizine 50 mg IV/IM/PO 8 hrly PRN
Moderate to High
Cyclizine 50 mg IV/IM/PO 8 hrly PRN and Ondansetron 4 mg IV/IM/PO
8 hrly PRN
Other contributory Factors
Length of surgery
Type of surgery eg. gynaecological, abdominal, laparoscopic.
Type of anaesthetic eg. inhalational anaesthesia.
Treatment of PONV – Recovery and Ward
PONV
score
0 – None
1 – Mild
2 – Moderate
3 – Severe




Maximum dose in 24 hours for Cyclizine – 150mg
Use 25mg -50mg slow IV injection of Cyclizine in elderly as
Pageconfusion
14 of 28
this may cause
Maximum recommended dose of Ondanestron 16 mg in 24 hours.
Keep IV cannula in situ until PONV score is 0.
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
PONV
Score 1-3
NO
Continue PONV
scoring
YES
Has Cyclizine been
administered > 30 minutes ago?
YES
NO
Give Cyclizine 50mg IV/IM
reassess in 30 min.
Give Ondansetron 4mg
IV/IM.
NO
Continue PONV
scoring
PONV
Score 1-3
PONV
Score 1-3
NO
Continue
PONV
scoring
YES
Give Ondansetron 4mg IV/IM
YES
Consult Anaesthetist/
surgical team
PONV
Score 1-3
Consider Dexamethasone phosphate 5-10mg IV/IM.
Ensure adequate analgesia including non-opioids,
adequate hydration, oxygenation, warmth & comfort.
Consider other contributing factors, including opioid use
and surgical complications.




NO
YES
Continue
PONV
scoring
Consult anaesthetist/
surgical team
PONV can cause dehydration, electrolyte imbalance, disrupt surgical wounds and delay recovery.
Consider regular dosing if PONV scores remain high. Review after 48 hours.
Consider oral route of anti-emetic if appropriate.
For contraindications and side effects see BNF.
Page 15 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
PART 2
PATIENT CONTROLLED ANLGESIA (PCA) POLICY
FOR CHILDREN
Page 16 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
CONTENTS
1
2
3
4
4.1
4.2
4.3
4.4
5
6
6.1a
6.1b
7
8
9
9.2
10
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
11
12
13
Contact Details
Introduction
Aims
Education and Training
Patient Selection
Contra-indications for PCA:
Extra care should be exercised in the selection of patients if they
have:
Age Related Considerations
Personality Traits
Patient Information
PCA Prescription
Children over 50 KG
Children less than 50 KG
Multi-modal Analgesia
Equipment
Monitoring and Documentation
Frequency for monitoring vital signs
Side Effects and Problems
Nausea and vomiting
Respiratory Depression and Over Sedation
Inadequate Analgesia
Urinary Retention
Mobility
Pruritis
Constipation
Pump Problems
Discontinuation
Successful outcome criteria
Monitoring compliance and effectiveness
Paediatric References
Page 17 of 28
Page
18
19
19
19
19
19
19
19
20
20
20
20
20-21
22
22
22
23
24
24
24
25
26
26
26
26
26
27
27
27
27
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Acute Pain Service West Herts NHS Trust
Contact Details
Lead Consultant for Acute Pain: - Dr. David Redman via anaesthetic office at WGH ext. 7604
Lead Anaesthetic Consultant for Paediatrics – Dr Albert Koomson
Watford General Hospital (WGH):Clinical Nurse Specialists (CNS):Linda Loader, Lead CNS for Acute Pain. Pager 07659 106855
Michelle Ashwell, CNS for Acute Pain,
Judith Nayler, CNS for Acute Pain, Pager: 07659 130558
Tracey Robertson, CNS for Acute Pain,
WGH ext. 3120; bleep 1120
SACH ext. 4660; bleep 2976
---------------------------------------------------------------------------
For Out of Hours Service and Covering Annual Leave
The Clinical Nurse Specialist will hold the Acute Pain bleep during working hour’s site specific.
The 1st on call anaesthetist will cover out of hours and Bank Holidays, please be aware that you may
not receive immediate response as they may be otherwise engaged. If there is no response, try the
on call anaesthetic registrar for ICU.
-------------------------------------------------
Page 18 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
1. Introduction
This policy covers the care and maintenance of Patient Controlled Analgesia systems (PCAs) within
West Hertfordshire Hospitals NHS Trust (WHHT). Part two of this policy is applicable to Paediatric
patients.
Wards and departments must be deemed competent in caring for patients receiving PCA by the ward
/ department manger. The manager holds responsibility for arranging training for their staff in the use
of PCAs.
2. Aims
The aims of this policy are:• To provide education and the rationale behind the uses of the PCA pump
• To provide consistent and effective pain relief through education
• To maintain patient safety and comfort by reducing and preventing side effects and problems
in the first instance and managing them effectively if they do occur.
3. Education and Training
3.1 Training and education is available via the ‘WHHT Learning Package for Nurses caring for
Paediatric Patients using Patient Controlled Analgesia Systems’ provided by the Acute Pain Service
(APS). The ward manager will identify any candidates needing training. Training should be booked
through the training department. Updates for training will be required every two years when new
competency sheets will be issued. It is the responsibility of the individual nurse and ward managers
to access staff training needs.
3.2 Patients receiving a PCA can only be cared for in an area where there are registered nurses who
have been deemed competent in caring for patients receiving PCA.
3.3 The Acute Pain Team (APT) advise that all wards that accept patients with PCA should have an
Acute Pain Link Nurse who has themselves been deemed competent in caring for patients receiving
PCA. It is the ward manager’s responsibility to identify their ward Link Nurse.
4. Patient Selection
PCA can be used for any patient with acute pain, where repeated doses of intramuscular or
intravenous opioids would otherwise be anticipated. This will include post-operative patients and
patients with acute painful conditions such as sickle cell disease.
4.1 Contra-indications for PCA:
• Patient/ parent/carer refusal
• Physical inability to operate the PCA demand button
• Impaired mental status
• Head injury
• Insufficient numbers of trained staff to ensure patient safety
4.2 Extra care should be exercised in the selection of patients if they have:
•
Marked electrolyte imbalance
•
Opioid dependence
•
Previous history of opioid related side effects
4.3 Age Related Considerations
Children who are suitable for using PCA are identified by the anaesthetists before they have their
operation. The Child must (a) have the physical ability to push the button of the handset. (b) have a
basic understanding of what happens when the button is pushed.16
Page 19 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
4.4 Personality Traits
Not everyone benefits from PCA. It is beneficial for patients who like to maintain control of their
environment, but some patients do not want to accept this responsibility. Some children like to block
2
out potentially unpleasant experiences and are more likely to expect the Health Care Professional or
an adult to take responsibility for their pain relief. These children are unlikely to use the PCA to its
full potential. If PCA is not being used effectively, it can be equivalent to no pain relief at all;
therefore the method of pain relief should be reviewed. Contact the APT Monday – Friday 9.00 –
17.00, outside these hours contact the first on call anaesthetist, an alternative mode of analgesia
may be decided upon.
Many parents and carers fear addiction to analgesia and may have been exposed to negative reports
of opioids from the media. This fear may have taken years to develop and rarely subsides with a
brief discussion about the use of opioids for pain relief3,4. This may affect their willingness for their
child to utilise the PCA to its full potential.
Patients’ appropriateness for PCA will be decided by the anaesthetist or Acute Pain Clinical
Nurse Specialist after discussion with the patient, parent/carer and ward nurse.
5. Patient Information
Children in whom PCA is planned should receive an explanation of the technique by the Anaesthetist
/ Nursing staff. This should then be reinforced when appropriate in the recovery unit. Ward staff
should also provide the patient with verbal information about the PCA. The written information can be
obtained from the ward and / or pre assessment clinic.
It is sometimes possible to highlight and address any concerns the patient and child may have when
talking to them before the PCA is started.
6. PCA Prescription
6.1 The PCA must be prescribed on the PRN side of the prescription chart, including the route, drug
concentration, bolus size and lockout period; this should be signed and dated by the prescriber e.g:6.1a Children over 50 KG may receive a prefilled syringe of Morphine sulphate 50 milligrams (mg)
pre diluted up to 50 ml with 0.9% sodium Chloride and prescribed as below.
Drug: Morphine sulphate via PCA
Additional Instructions
50mg morphine in 0.9% Sodium Chloride
Total 50ml pre filled syringe
Signature:
Dose:
1mg bolus
Route
Date:
IV
25/12/2010
Max. Frequency
Jo Brown
5min. lock out
Any loading doses should be prescribed as ‘stat doses’ on the front of the drug chart, in the once only
section.
6.1b Children less than 50 KG – The body weight of the child in mg diluted up to 50 ml with 0.9%
sodium chloride e.g. 35 kg child use 35 mg of morphine made up to a total volume of 50 mls with
0.9% sodium chloride. This gives a concentration of 20 micrograms/kg/ml (or concentration of 700
micrograms/ml)
Page 20 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Drug: Morphine sulphate via PCA
Dose:
700 micrograms = 1ml
Additional Instructions
35mg morphine made up to 50 ml
With 0.9% Sodium Chloride
Route
IV
Signature:
Jo Brown
Max. Frequency:
5 min lock out
Date
25/12/2010
Any loading doses should be prescribed as ‘stat doses’ on the front of the drug chart, in the once only
section.
6.2 For children over 50 Kg a standard pre-filled syringe of morphine sulphate solution should be
used:- morphine sulphate 50mg in a total of 50ml of 0.9% sodium chloride. Using pre filled syringes
that the Trust purchases, is aimed at reducing the risk of needle stick injury and error of incorrect
dilution. If these are not available, Pharmacy should be contacted for further guidance.
6.3 Other opioids may be used as an alternative if morphine is not appropriate for the patient, but
must be discussed with an Anaesthetist or the Acute Pain CNS first. Do not use Appendix 1 and 2
consult with the anaesthetist if the child has a morphine allergy.
6.4 The pumps should only be programmed by an Anaesthetist, Acute Pain CNS, trained recovery
staff or a member of staff who has been specifically trained by the Acute Pain CNS and deemed
competent to do so.
6.5 PCA syringes can be changed by any qualified nurse who has been assessed as
competent in administering intravenous medication and successfully completed the ‘WHHT
Learning Package for Nurses caring for Paediatric Patients using Patient Controlled
Analgesia Systems’.
6.6 Additional doses of opioids (loading doses) should only be administered by the Anaesthetist or
Acute Pain CNS. Qualified nursing staff in recovery who have been deemed competent by the
Recovery Unit Sisters, may administer loading doses as prescribed for patients in recovery.
6.7 Naloxone should always be prescribed on the PRN side of the drug chart when a PCA is in use. It
should be administered to keep the patients respiratory rate above normal ranges which can be see
below.
Age Ranges
Respirations (breath
per minute
2-5 years
5-12 years
12 years
25-30
20-25
15-20
Naloxone IV injection:
1 month – 12 years: 5-10 micrograms/kg if no response subsequent dose of 100 micrograms/kg
(max 2mg)
12 – 18 years: 1.5 – 3 micrograms/kg if response inadequate, give increments of 100 micrograms
every 2 minutes (check CBNF)
Page 21 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
7. Multi-modal Analgesia
Using only one approach to managing pain can be ineffective for many patients; several different
pains may contribute to their overall symptoms7. A balanced approach, using several analgesics with
differing mechanisms of action, has been shown to be more effective and to reduce the risk of side
effects of opioids. A combination of different drugs that act at different stages of the pain pathway
maximise the amount of pain relief. All drugs should be correctly prescribed on the patients drug
chart before administration.
Where possible PCA should be given concurrently with paracetamol iv/po and/or a Non Steroidal Anti
Inflammatory Drug, (NSAID) via an appropriate route, ensure NSAID’s are not contraindicated, (see
CBNF for contraindications17). It is not advisable to give diclofenac (Voltarol) intramuscularly as it is
very painful and can cause abscesses and local necrosis at the intramuscular injection site6.
Paracetamol and/or a NSAID should be given on a regular basis in conjunction with the PCA if
prescribed.
No other opioids including codeine, dihydrocodeine, tramadol or compound analgesics i.e. codydramol should be administered whilst the patient is receiving PCA, (this will minimise the risk of
respiratory depression) unless advised by Anaesthetist or Acute Pain CNS and concurrent
administration must be stated on the drug chart
8. Equipment
8.1 PCA delivery is via the Graseby 3300 machine that requires a 50 ml syringe clearly identified with
the drug and concentration, patients’ details, date and time infusion commenced. An appropriate
giving set with anti-syphon and anti-reflux properties must be used and a labelled PCA line, these
can be obtained from the recovery unit if required.
8.2 The opioid of choice and purchased as pre filled syringes for PCA use is Morphine Sulphate
1mg/1ml 50 ml syringe these are available to order from Pharmacy. The 50 ml syringe is used for
patients over 50 kg in weight for patients under 50 kg the correct concentration must be prepared by
the nursing or medical staff as 6.1b above.
8.3 The PCA must have a dedicated Vygon PCA administration line which has an anti syphon value
at the distal end that attaches to the syringe. Its other property is, at the proximal end (patient end)
there is a side port with anti reflux value where maintenance fluids or other infusions that are
compatible with the morphine, may be attached. The use of the side port helps prevent premature
blockage of the cannula and reduces the need for separate flushing of the cannula or the need for a
second cannula.
8.4 All IV cannula and lines must be changed according to hospital policy, 48 hours for solution
10
sets . The giving sets for PCAs are kept in recovery. The Graseby 3300 pump can be obtained from
the Medical Electronics Library 09.00 – 17.00 Monday to Friday and from recovery out of hours. The
morphine sulphate syringe should be obtained form the ward / department controlled drug cupboard
the patient is in at the time required.
8.5 The patients’ cannula should be secured with a transparent dressing. The administration line,
tubing can then be secured to the patient if required. The cannula should be easily visible and
accessible (see 9.4 below).
9. Monitoring and Documentation
9.1 All patient vital signs /clinical observations for the duration of the PCA should be recorded on the
‘Paediatric Patient Controlled Analgesia Systems (PCAs) Guide’
9.2 Frequency for monitoring vital signs (as per care plan)
Page 22 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
Monitor
First
hour
¼ hrly
Next
2
hours
½ hrly
Next
4
hours
1hrly
Respiratory
rate
Remainder of time while on
PCA
Hourly
Sedation score
¼ hrly
½ hrly
1hrly
Hourly
Blood Pressure
¼ hrly
½ hrly
1hrly
According to clinical need
Heart Rate
¼ hrly
½ hrly
1hrly
Hourly
Pain Score
¼ hrly
½ hrly
1hrly
Hourly
The patients’ respiratory rate and sedation score should be monitored 1-2 hourly for the duration of
the PCA according to clinical need this is necessary due to the side effect profile of opioids.
9.3 The following observations are also mandatory when a patient is receiving opioids via a PCA and
should be documented 1-4hrly in the appropriate place on the ‘Paediatric Patient Controlled
Analgesia Systems (PCA) Guide’ or more frequently if clinically indicated.
PCA number of demands, number of good demands, total amount of drug given
Nausea and vomiting score
Itching (pruritis) score
Pain score should always be assessed on movement e.g. coughing, deep breathing. If the pain score
is greater than >1 (0 = none 3 = severe) at any time this must be addressed and reassessed in ½
hour and then recorded hourly until a score of 1 or (<1) below 1 has been established.
Face 0
No pain
Face 1
Hurts just a bit
Face 2
Hurts quite a bit
Face 3
Hurts a lot
Pain cannot be treated adequately if it is not assessed regularly
9.4 IV cannula site to be checked 4 hourly for inflammation, redness etc. If indicated the cannula
should be re-sited.
9.5 The Acute Pain Team aim to visit the patients daily if possible Monday to Friday.
In the absence of the Acute Pain Nurse the 1st on call anaesthetist should be contacted to deal with
any pain management problems that the patients’ clinical teams cannot manage.
9.6 All patients receiving PCA should have a Pain Service Audit Sheet started in recovery. The
Recovery staff should fill this in if the patient has been nursed in Recovery. If the Anaesthetist starts
Page 23 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
the PCA on the ward then the Anaesthetist should complete the form. The audit form ensures that
the patient will receive appropriate follow-up care by the Acute Pain Team.
9.7 If a paediatric patient with PCA are returning to the wards from the Intensive Care Unit (ICU) or a
tertiary hospital, staff should inform the Acute Pain Nurse regarding the patients’ transfer.
10. Side Effects and Problems
10.1 Nausea and vomiting
The incidence of postoperative nausea and vomiting depends on many factors including the
anaesthetic used, the type and duration of surgery and the patient’s gender. The aim is to prevent
postoperative nausea and vomiting from occurring. The nurse or doctor should evaluate the response
to any anti-emetic after administration and if the patient is still nauseated after 30 minutes a different
type of anti-emetic should be prescribed and administered. A combination of two antiemetic drugs
acting at different receptor sites may be needed in resistant postoperative nausea and vomiting.
The following are recommended by the APS:
1st drug of choice – CYCLIZINE17 IV
• 6 - 12 years 25 mg up to 3 times daily
• 12 – 18 years - 50 mg up to 3 times daily
Diluted in water for injection (5-10ml) and given by slow IV injection over 2-5 minutes
2nd drug of choice – ONDANSETRON17
• 2 - 12 years: 100 micrograms/kg (maximum 4 mg) as a single dose before, during, or after
induction of anaesthesia. Give by slow IV injection over 2-5 minutes
• 12-18 years: 4 mg, as single dose at induction of anaesthesia given by slow IV injection over 2-5
minutes
If postoperative nausea and vomiting (PONV) persists when the above are given regularly then
contact the APS or anaesthetist.
PCA should not be stopped because of nausea and vomiting unless prior discussion with the APS/
anaesthetist has taken place.
Children with a high risk of PONV can be prescribed one anti-emetic on a regular basis and one on a
as required (prn) basis.
10.2 Respiratory Depression and Over Sedation
10.2.1 If the respiratory rate becomes low for the Childs age and saturation <94%16 :Age Range
5-12years
12years and over
Respiration (breath per minute)
20
15
•
•
•
•
•
Remove the hand set from the child
Commence ¼ hourly respiratory rate and sedation scoring
Commence and maintain continuous pulse oximetry
Give oxygen as necessary according to prescription, keeping saturations above 94%
Inform Ward Paediatric registrar, 1st on-call anaesthetist and/or Acute Pain Team.
10.2.2 If the sedation score is 3 irrespective of respiratory rate:
0=Awake
1=Drowsy
2=Asleep (rousable) 3=Asleep (unrousable)
Page 24 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
•
•
•
•
•
•
•
•
Stop PCA
Inform Ward Paediatric registrar and Anaesthetist on call, Paediatric crash team if
applicable
Start Paediatric Basic Life Support
Administer high flow oxygen at 10-15 litres via a non-rebreathe bag and mask. This may
be administered without prescription in accordance with Trust oxygen policy.11
Commence pulse oximetry
Commence ¼ hourly observations of respiratory rate and sedation score.
Ensure a qualified nurse remains with the patient.
Prepare naloxone injection
AGE
1 month – 12 years
Naloxone IV injection
5
-10
micrograms/kg
if
response inadequate give a
subsequent dose of 100
micrograms/kg (max. 2mg)17
12 years – 18 years
1.5 - 3 micrograms/kg if
response
inadequate,
increments of 100 micrograms
every 2 minutes17
If a continuous intravenous 5 - 20 micrograms/kg/hour,
infusion is required:
adjust according to response17
1 month – 18 years
WHHT Guidelines for Administration of Naloxone for Adult and Paediatric Patients Receiving Patient
Controlled Analgesia and Adults only receiving Opioid Epidural Analgesia12.
10.3 Inadequate Analgesia
If a child has a pain score of greater than 1 (0=none 3=severe) on movement, action needs to be
taken.
There are several interventions that can be used and the choice will depend on the assessment of
the child. This should, where possible, be negotiated with the child. These are:
•
•
•
•
•
•
Re-educate patient in using PCA
Give prescribed multimodal analgesia
Check has the handset become disconnected from back of PCA?
Arrange for morphine bolus via PCA to be given (only given by anaesthetist or Acute
Pain Team. In recovery only the recovery nurse may give a bolus once prescribed,)
Reassure / Re-position patient.
Always check the IV site for patency, IV line that all clamps are open, extravasations
and signs of infection
PCA should not be stopped because of inadequate analgesia without prior discussion with
the APS.
The bolus dose may need to be altered, discuss with Acute Pain Team or
Anaesthetist on-call.
10.4 Urinary Retention
Contact the paediatricians for advice; the patient will need an assessment and may require a urinary
catheter.
Page 25 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
10.5 Mobility
Using a PCA does not prevent patients from mobilising. It is when the patient first starts to mobilise
that they may need to use the PCA more. The Graseby 3300 PCA pumps may be disconnected from
the electrical mains supply and can run on battery power for a short period of time (up to 7 hours
depending on battery charge). However to maintain battery charge the pump should always be
plugged in when possible.
PCA should not be stopped because the patient needs to mobilise.
10.6 Pruritis
If problematic for the patient, contact the doctor, APT to assess the patient. Chlorphenamine may be
prescribed, as required,
AGE
6 – 12 years
12 – 18 years
Chlorphenamine Maleate IV
injection17
5 - 10 mg, repeated if required
up to 4 times in 24 hours . Give
IV injection over 1 minute
10 – 20 mg repeated if required
up to 4 times in 24 hours (Max
40mg in 24 hours). Give IV
injection over 1 minute
Naloxone may be required. If a higher dose of naloxone is given this will reverse the analgesic effect
of the opioid.
10.7 Constipation
Patients receiving opioid analgesia may require a laxative prescribed regularly or the appropriate
health education to help manage any constipation.
10.8 Pump Problems
If the pump alarms, the cause for the alarm will appear on the pump screen. Check the cause by
reading the screen then silence the alarm. Refer to Manufacturers Guidelines (found in The Acute
Pain Resource Folder) to resolve these problems. Ensure PCA line is not clamed in PCA lid and that
all line clamps are open.
If a fault code appears:•
•
•
•
Turn off the pump immediately and remove it from the patient
Call the APT / Anaesthetist to initiate another PCA pump if the ward staff are not trained to do
so.
Medical Electronics Library should be informed of the type of fault as soon as possible.
Document the pump number and fault code that appeared on the pump. Attach this
information to the pump to assist in the correct pump being serviced.
Consider if an Incident Form needs to be completed e.g. incorrect dose of morphine being
administered.
11. Discontinuation
If the child is comfortable and pain free, it is likely that the patient’s analgesia is at a correct level. It
is not necessarily an indication for stopping the PCA. However, once a child is able to eat and drink
and their PCA opioid usage is minimal this may be an appropriate time to consider changing the
analgesia to oral medications.
Page 26 of 28
Patient Controlled Analgesia (PCA)
Policy for Adult and Paediatric patients. September 2009. V1
The opioid PCA should be discontinued after discussion and agreement with the child. The child
should be able to transfer onto oral medication. It is not advisable to stop PCA analgesia in favour of
intramuscular analgesia.
Initially after stopping the PCA analgesia oral analgesia should be given regularly. The multimodal
rules (see section 7 above) also apply to oral analgesia. If the patient has not been taking
supplementary analgesia such as paracetamol and / or NSAIDs (if no contraindications), commence
this prior to stopping the PCA. This will reduce the level of mild or strong opioid analgesia the patient
will require.
After discontinuation of the PCA, the pain score should continue to be documented on the Patient
Observation chart with every set of observations, remembering that pain is the 5th vital sign. This is
vital in order to assess that the alternative oral analgesia continues to control the child’s pain
adequately.
Any remaining opioid in the PCA syringe, when discontinued, must be destroyed by putting into
gauze/paper towel and put into the clinical waste bin/sharps bin, as per ‘WHHT, Medicines
Management Policy, incorporating, The Policy for Prescribing, Administration and Supply of Drugs’13.
When the PCA has been discontinued the PCA pump should be decontaminated and returned to the
Medical Equipment Library at WGH.
12. Successful outcome criteria
• Patient indicates that their pain level is at a level acceptable to them
• Patient indicates that they are satisfied with this method of analgesia
• Patient indicates that they have participated in their own pain management
• There is written evidence that the patient has a pain score of 0 or 1
13. Monitoring Compliance and Effectiveness
• Annual Audit
• Acute Pain Team will audit all patients with PCAs on a daily basis (other than weekends and bank
holidays when it is down to the on call anaesthetist) any deviations from the policy will be reported
and monitored through Clinical Governance Meetings.
Paediatric References
16. Morton NS., Saunders WB., Acute Paediatric Pain Management. A practical Guide. Harcourt
Brace and Company Ltd. P254. 1998
17. BNF for children, 2008. Published by BMJ Publishing Group Ltd. Tavistock Square, London,
WC1H 9JP, UK
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